R 5163 PERMIT R. 5163
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
•
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/ / 19 LJ'� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME QHLq roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS '- EXISTING ROOF COVERING
PHONE S rD —Z"'3 NUMBER OF EXISTING COVERINGS ,
CONTRACTO
TO BE REMOVED / TO BE RETAINED
NAME rJ�lLQiGGGtc� � � -
ADDRESS �yJ- ,r / TYPE OF ROOF COVERING
CITY&ZIP
-
EXISTING
PHONE_POO L�f�,F-7�(0 BUILT-UP ROOF
LICENSE
NUMBER (o/8G646.9 ASPHALT SHINGLES
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I em licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business end Professions Cotle,and my license Ie In lull force and
meat. WOOD SHINGLES 1:1License Claes Ut:.Number
Date /< <_�contractor OTHER(SPECIFY) p
OWNERBUILDER OECLARAfION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason,
IS
7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF El
app
for such permit to file a signed statement that he Is licensed pursuant to the provisions
• of the Contractor's License Law(Chapter a(commenclng with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 30 Y A
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAKES
C]1.as owner of the property,or my employees with wages as their Sole compensation,will do P a
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profits. p+s Y
alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑���
such Improvements are not Intended or offered for sale.If,however,the building or Improvement 0 O Ls
is sold within one year of completion,the owner-builder will have the bu rden of proving that he did OTHER(SPECIFY) V ll
not build or Improve for purpose of sale.).
C]1,as owner of the property,am exclusively contracting with licensed contractors to construct k.0 j 1)VV
theproject(Sec.70",Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPC`RTINO�r
apply to an owner of property who builds or Improves thereon,and who contracts for such projects til I
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:11 am exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, 00 Building / :27,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this C/ nn
p rml leeuetl. /` G//[� 77 Soo Seismic - 80
eve antl will themaintainrt Worker's Compensation Insurance,as requiredsu d.My
3700 of
lh Labor Code,for the performance of the work for which this permit is Issued.My Worker's 7 f,
ompenea n Insure a carrier and Polley nu r aro: ''11.. 11 y�I'./� Total / - 6 b
Carrier � '64-W!24 PoIICy No.BIOr-32 /�r4V7-0J PERMIT AUTHORIZAT N DATE
CERTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.] /
(This section need not be completed II the permit Is for one hundred dollars($100)or lees.)
I certify that In the performance of the work for which this permit Is Issued.1 shell not employ I
any person In any manner so as to become subject to the Workers'Compensellon Laws 01 CSII All roofs shall be inspect prior to any roofing material being
fornix' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non point
with such provisions or this permit shelgbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information is correct.I agree
to hereby authorize
all citrase county ordinances his cec and terntate on thel ting above-mentingioned
dpro property
and All roof COyeflflQS to be aSS or better.
hereby authorize repreeemetives of this city to enter upon the ebevementlonetl property for In.
speedo) rpoaee.
(We)agree to save,indemnify and keep harmless the City of Cupertino against Ilebllllles, G(/
judgmania,costa and expenses which may In anyway accrue against sold City In mnsequenca
of Iha gremmo of lms permit SIGNATOR F APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE:'OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPV